HESI LPN
HESI Pediatrics Quizlet
1. A parent tells the nurse in the emergency department, 'My 3-year-old has had a fever for several days and has been vomiting.' After instituting ordered measures to reduce the fever, what nursing action is most important?
- A. Preventing shivering
- B. Restricting oral fluids
- C. Measuring output hourly
- D. Taking vital signs hourly
Correct answer: A
Rationale: Preventing shivering is crucial in this scenario as it can increase body temperature and counteract the effects of antipyretic measures aimed at reducing the fever. Shivering generates heat through muscle activity, which can elevate the body temperature. Restricting oral fluids (choice B) is inappropriate as maintaining hydration is vital, especially in cases of fever and vomiting. Measuring output hourly (choice C) and taking vital signs hourly (choice D) are important nursing actions but not the most critical in this case where preventing shivering takes precedence.
2. A client with diabetes mellitus is receiving insulin glargine (Lantus). The nurse should monitor the client for which of the following side effects?
- A. Hypoglycemia
- B. Hyperkalemia
- C. Hypertension
- D. Hypercalcemia
Correct answer: A
Rationale: Insulin glargine is a long-acting insulin used to control blood sugar levels in diabetes. The nurse should monitor the client for hypoglycemia, which is a potential side effect of insulin therapy. Hypoglycemia occurs when blood sugar levels drop too low, leading to symptoms such as shakiness, dizziness, sweating, confusion, and in severe cases, loss of consciousness. Hyperkalemia (choice B) is an elevated potassium level, not typically associated with insulin glargine. Hypertension (choice C) is high blood pressure, which is not a common side effect of insulin glargine. Hypercalcemia (choice D) is an elevated calcium level and is not related to the use of insulin glargine.
3. A 16-month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her, and begins to cry. What would be the initial action by the nurse?
- A. Arrange for a change in client care assignments
- B. Explain that this behavior is expected
- C. Discuss the appropriate use of 'time-out'
- D. Explain that the child is in need of extra attention
Correct answer: B
Rationale: The correct answer is to explain that this behavior is expected. At 16 months of age, children commonly experience separation anxiety, especially in unfamiliar environments like hospitals. It is important for the nurse to reassure the child and the parent that such behavior is normal. Option A is incorrect as there is no need to change client care assignments based on the child's behavior. Option C is not appropriate as discussing the use of 'time-out' is more relevant in behavior management for older children. Option D is incorrect as it does not address the underlying cause of the child's behavior related to separation anxiety.
4. The parents of a 1-month-old girl with Down syndrome are being taught by the nurse on how to maintain the child's good health. Which instruction would the nurse be least likely to include?
- A. Getting cervical radiographs between 3 and 5 years of age
- B. Adhering to the special dietary needs of the child
- C. Getting an echocardiogram before 3 months of age
- D. Monitoring for symptoms of respiratory infection
Correct answer: B
Rationale: The correct answer is B. While special dietary needs may be important, they are not typically a primary concern for a 1-month-old with Down syndrome compared to monitoring for congenital issues. Getting cervical radiographs, an echocardiogram, and monitoring for respiratory infections are more crucial in the early care of a child with Down syndrome. Cervical radiographs help in assessing for atlantoaxial instability, an echocardiogram is important for detecting congenital heart defects common in Down syndrome, and monitoring for respiratory infections is vital due to the increased risk in these children.
5. A 4-year-old child is brought to the emergency department with a suspected fracture. What is the priority nursing action?
- A. Immobilize the affected limb
- B. Apply ice to the affected area
- C. Elevate the affected limb
- D. Check the child's neurovascular status
Correct answer: A
Rationale: The priority nursing action when a child with a suspected fracture is brought to the emergency department is to immobilize the affected limb. Immobilization helps prevent further injury until a fracture is confirmed or ruled out. Applying ice or elevating the limb may be necessary interventions but should come after immobilizing the limb. Checking the child's neurovascular status is important but should follow immobilization to ensure no further harm is done during the assessment.